The 2016 Medicare Physician Fee Schedule’s Impact on …€¦ · The 2016 Medicare Physician Fee...

The 2016 Medicare Physician Fee Schedule’s Impact on Pathology Services

Jonathan L. Myles, MD, FCAP W. Stephen Black-Schaffer, MD, FCAP Diana M. Cardona, MD, FCAP John Scott, VP CAP Policy and Advocacy

November 5, 2015

2016 Medicare Physician Fee Schedule

• Final 2016 Medicare Physician Fee Schedule was released on October 30

– Proposed fee schedule published in July

– CAP members received a STATLINE Alert with initial analysis of the final rule

• CAP will continue to engage with the Centers for Medicare & Medicaid Services (CMS)

– Including formal comments due December 29

© 2015 College of American Pathologists. All rights reserved. 2

Agenda

• Payment for Pathology Services

• Reimbursement Policy Changes

• Quality Reporting Initiatives

• Questions


Welcome

Jonathan L. Myles, MD, FCAP

• Chair, CAP Economic Affairs Committee

• Pathology Advisor to the AMA-RUC


Welcome

W. Stephen Black-Schaffer, MD, FCAP

• Vice Chair, CAP Economic Affairs Committee


Welcome

Diana M. Cardona, MD, FCAP

• EAC Measures & Performance Assessment Subcommittee Chair


Payment for Pathology Services




Specialty Allowed Charges (millions)

Impact of Work RVU Changes

Impact of PE RVU Changes

Impact of MP RVU Changes

Combined Impact

Pathology $1,330 4% 4% 0% 8%

Independent Laboratory

$834 1% 7% 0% 9%

*Does not equal sum of RVU columns due to rounding.

• Reflect averages by specialty (based on Medicare utilization)

• For individual physicians and practices, the impact depends on mix of services and payers (Medicare and non-Medicare)

• Physicians receive pay from other Medicare payment systems

o For instance, independent laboratories receive 83% of their Medicare revenue from CLFS

Payment for Pathology Services • CMS finalized partial increases sought by the CAP

for pathology services, including – Immunohistochemistry

– In situ hybridization

• CMS implemented an update to many of the payment rates and accepted some of CAP’s and American Medical Association (AMA) Relative Value Update Committee’s (RUC) recommendations

• CMS implemented cuts to prostate biopsy services



• Protecting Access to Medicare Act (PAMA) of 2014 established a new annual target for reductions in expenditures resulting from adjustments to the relative values of misvalued codes

• New statute sets a 1% annual target – CMS achieved 0.23% net reduction on targeted services

• CMS applied a 0.77% across-the-board cut to all physician fee schedule services


Prostate Biopsy Services

• In 2009, CMS created four G codes for the surgical pathology of prostate saturation biopsy services.

• CMS changed the set of descriptors in 2013, 2014, and in 2015.

• 2015 changes eliminated codes G0417, G0418, and G0419, and revised the descriptor for G0416 – the code would apply to all prostate biopsy specimens regardless of the number of specimens or technique used to obtain the biopsy.

• CMS stated this simplified the coding and mitigated overutilization incentives.




• For 2015, G0416 was identified by CMS as a potentially misvalued service.

• The AMA RUC and CMS evaluated the technical component direct practice expense inputs and the professional component in 2015 because they were based on outdated information and a coding structure that no longer exists.

CPT Code MOD DESCRIPTOR 2015

Payment 2016

Payment Percentage

Change

G0416 Prostate biopsy, any mthd $649.32 $533.84 -17.8%

G0416 26 Prostate biopsy, any mthd $182.90 $158.00 -13.6%

G0416 TC Prostate biopsy, any mthd $466.42 $375.83 -19.4%



• Due to the TC review and shifts in medical service volume from the change in the description of service, the payment for these services decreased significantly. These decreases will be phased in over two years, barring any other changes to the 2017 values.

• CMS anticipates a RUC recommendation for the work RVU for 2017. The CMS may then alter the work RVU for 2017.

CPT Code MOD DESCRIPTOR 2015

Payment 2016

Payment Percentage

Change

G0416 Prostate biopsy, any mthd $649.32 $533.84 -17.8%

G0416 26 Prostate biopsy, any mthd $182.90 $158.00 -13.6%

G0416 TC Prostate biopsy, any mthd $466.42 $375.83 -19.4%

Immunofluorescent Studies


CPT Code MOD

2015 Work RVU

2016 Work RVU

2015 PE

RVU

2016 PE

RVU 2015

Payment 2016

Payment Percentage

Change 88346 0.86 0.74 2.21 1.85 $111.03 $93.87 -15.5% 88346 26 0.86 0.74 0.35 0.31 $43.84 $38.34 -12.6% 88346 TC 0.00 0.00 1.86 1.54 $67.20 $55.53 -17.4% 88350* NA 0.56 NA 1.45 NA $72.37 NA

88350* 26 NA 0.56 NA 1.22 NA $28.66 NA

88350* TC NA 0.00 NA 0.23 NA $43.71 NA

For CPT 2016, the Panel revised 88346, created add-on code 88350, and deleted 88347.

88346 - Immunofluorescence, per specimen; initial single antibody stain procedure

88350 - Immunofluorescence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)

* 88350 is a new CPT code for 2016

Payment for Pathology Add-on Services


CPT Code DESCRIPTION

Work RVU 2015

Work RVU 2016

Change in Work

RVU

Percentage Change in Work RVU

88350 Immunofluor addl antibody stain NA 0.56 NA NA

88341 Immunohisto addl antibody slide 0.42 0.53 0.11 26%

88364 In situ hybridization addl probe(fish) 0.53 0.67 0.14 26%

88369 M/phmtrc alys ish quant/semiq addl probe 0.53 0.67 0.14 26%

Payment for In Situ Hybridization

CPT Code MOD DESCRIPTION

2015 Payment

2016 Payment

Percentage Change

88368 Insitu hybridization manual $109.24 $115.01 5%

88368 26 Insitu hybridization manual $41.32 $41.20 0%

88368 TC Insitu hybridization manual $67.91 $73.81 9%

88369 M/phmtrc alys ish quant/semiq addl probe $74.02 $108.56 47%

88369 26 M/phmtrc alys ish quant/semiq addl probe $25.15 $31.89 27%

88369 TC M/phmtrc alys ish quant/semiq addl probe $48.87 $76.67 57%

88377 M/phmtrc alys ishquant/semi multiplex $214.88 $412.02 92%

88377 26 M/phmtrc alys ishquant/semi multiplex $65.76 $66.28 1%

88377 TC M/phmtrc alys ishquant/semi multiplex $149.12 $345.74 132%





2015 Payment

2016 Payment

Percentage Change

88184 Flowcytometry/ tc 1 marker $94.51 $76.31 -19%

88185 Flowcytometry/tc add-on $57.49 $46.22 -20%

88312 Special stains group 1 $98.10 $98.89 1%

88312 26 Special stains group 1 $28.03 $28.30 1%

88312 TC Special stains group 1 $70.07 $70.58 1%

88313 Special stains group 2 $68.27 $69.15 1%

88313 26 Special stains group 2 $12.58 $12.54 0%

88313 TC Special stains group 2 $55.70 $56.61 2%

88314 Histochemical stains add-on $75.10 $78.10 4%

88314 26 Histochemical stains add-on $23.00 $23.29 1%

88314 TC Histochemical stains add-on $52.10 $54.82 5%

Payment for Immunohistochemistry



2015 Payment

2016 Payment

Percentage Change

88341 Immunohisto addl antibody slide $67.91 $90.64 34%

88341 26 Immunohisto addl antibody slide $21.92 $27.95 28%

88341 TC Immunohisto addl antibody slide $45.99 $62.70 36%

88342 Immunohisto initial antibody stain $90.91 $107.48 18%

88342 26 Immunohisto initial antibody stain $36.65 $37.26 2%

88342 TC Immunohisto initial antibody stain $54.26 $70.22 29%

88344 Immunohisto per specim multiplex $117.50 $173.77 48%

88344 26 Immunohisto per specim multiplex $40.25 $40.84 2%

88344 TC Immunohisto per specim multiplex $77.26 $132.92 72%

Payment for Surgical Pathology


CPT Code MOD DESCRIPTION 2015 Payment 2016 Payment

Percentage Change

88304 Tissue exam by pathologist $45.99 $46.22 1%

88304 26 Tissue exam by pathologist $11.86 $11.82 0%

88304 TC Tissue exam by pathologist $34.14 $34.39 1%










Reimbursement Policy Changes


Reimbursement Policy Changes

• CMS proposed to impact pathologists practice expense RVUs by making wide-ranging standardizations to clinical labor tasks and time across codes.

– CAP advocated that pathology services are unique and should not be subject to blanket standardizing edits. o Importantly, CMS did not appear to consider how

differing batch and block sizes across codes would interact with the new standard times.

– The Agency mostly agreed with the CAP and only finalized 6 of the 17 proposed standardizations.

– The CAP continues to work with the agency on this and other practice expense issues.


Misvalued Code Initiative

• CMS proposes to continue its work examining potentially misvalued services

• This may include physician work surveys, data collection, research, and/or analyses

• CMS also may use analytic contractors


Misvalued Code Initiative


Potentially Misvalued Codes Listed in the Final 2016 Medicare Physician Fee Schedule

Code Short Description

10022 Fna w/image

36516* Apheresis selective

38221 Bone marrow biopsy

88185 Flowcytometry/tc add-on

88189 Flowcytometry/read 16 & >

88321 Microslide consultation

88360 Tumor immunohistochem/manual

88361 Tumor immunohistochem/comput

Hospital Data

• CMS continues to believe that there are various possibilities for leveraging hospital cost data in technical component methodology in the fee schedule.

• CAP continues to disagree with the agency’s understanding of the substantial differences in the cost methodologies of the physician fee schedule and hospital cost data.


Physician Self-Referral Update

• The final rule contained two new exceptions: – The recruitment of non-physician practitioners – Time share arrangements

• Time share arrangements include hospitals or local physicians who make equipment and services available to an independent physician to treat patients.

• The timesharing can only include laboratory services, simple tests such as ones for strep throat, checking one’s glucose, or monitoring of blood thinners, that are CLIA waived.

• CMS stated it could not “be certain a timeshare arrangement would pose no risk of program or patient abuse”


Quality Reporting Initiatives


Final 2016 Fee Schedule Highlights

• All eight pathology measures are retained in the 2016 Physician Quality Reporting System (PQRS).

• CMS clarifies pathologists billing from independent laboratories are not subject to PQRS payment adjustments.

• PQRS and Value-Based Modifier (VBM) programs expire after 2018 and are replaced by the new Merit-Based Incentive Payment System (MIPS).


Pathology Measures

• Breast Cancer Resection Pathology Reporting

• Colorectal Cancer Resection Pathology Reporting

• Barrett’s Esophagus

• Radical Prostatectomy Pathology Reporting

• Immunohistochemical (IHC) Evaluation of HER2 for Breast Cancer Patients

• Lung cancer reporting (biopsy/cytology specimens)*

• Lung cancer reporting (resection specimens)*

• Melanoma reporting* © 2015 College of American Pathologists. All rights reserved. 28


• 2016 PQRS will affect 2018 PQRS, VBM penalties – Separate -2% penalty under PQRS program – +/- 4% VBM adjustment for physicians in groups 10 or more

– +/- 2% VBM adjustment for solo physicians, groups 2-9

• VBM will apply to all physicians

• Successful PQRS participation in 2016 will stop the 2018 PQRS penalty and automatic VBM penalty.



• VBM score is a calculation based on performance of the Group (defined by tax identification number (TIN))

– Quality performance

– Cost measures, which are based on the total cost of care attributed to the primary care physician

– For pathology, we are considered to be average cost providers because we do not provide primary care services


Quality Reporting Initiatives* (All Physicians are Subject to Quality Tiering)


Successful PQRS Participants in groups of 10 or more Quality/Cost Low Cost Average Cost High Cost

High Quality +4.0x* % +2.0x* % +0.0%

Average Quality +2.0x* +0.0% -2.0%

Low Quality +0.0% -2.0% -4.0%


• Medicare Access and CHIP Reauthorization Act from April 2015 establishes the Merit-Based Incentive Payment System (MIPS) in 2019.

– MIPS scores are dependent upon quality, resource use, EHR, and clinical practice improvement activities

– CAP provision in the law provides flexibility for pathologists in the MIPS

• CAP will engage with CMS on the new program


Questions


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